Hole in MARs

[kcochrane]

Hi,

We have an ongoing problem with holes in our paper MARs. Anyone have any solution(s) they've used to help with this issue. We've tried making the nurses check each other MARs at the end of the shift, but it hasn't worked well. I know this issue will go away once we get electronic MARs, but that may not be for another year. Thanks!

[JKL33]

What do you mean - physical holes? What is the mechanism causing the holes? Why would there be holes in them other than for use of a ring binder? People aren't erasing things, I sure hope. So where are the holes coming from - Mice? Erasing? Employees with pica?

[caliotter3]

Do what a couple of my employers have done in the past, make the offenders come in on their own time to fix their charting.

[JKL33]

Okay, just to clarify, I was not trying to be a SA with my first reply - that was just what I thought of when I read "paper." Deficiencies in transcribing orders from old sheet to new could also be called holes.

Regardless of what kind of holes these are, your place chose to make RNs do something to correct a problem without understanding the cause of the problem. Not rare...just rarely successful.

Why do the nurses say this problem is happening?

[Jedrnurse, BSN, RN]

Okay, just to clarify, I was not trying to be a SA with my first reply - that was just what I thought of when I read "paper." Deficiencies in transcribing orders from old sheet to new could also be called holes.

Regardless of what kind of holes these are, your place chose to make RNs do something to correct a problem without understanding the cause of the problem. Not rare...just rarely successful.

Why do the nurses say this problem is happening?

For those who "grew up" in the days of paper MARs, holes were a big thing. Especially in LTC, where a given patient's MARs can be VERY numerous, with some things needing to be signed off QID, for example.

Admin would say that these are med errors, because "if it's not charted, it's not done." (My experience has taught me that "just because it's charted, doesn't mean it was done", but that's another story altogether...)

We would have nights audit the MARs and make notes of the holes. Sometimes the DON would do it as well. It was an eternal battle with no end in sight...

[JKL33]

I was around for paper MARs. :)

Never worked as an RN in LTC though. So the holes being referred to are those tiny check-boxes - empty because something didn't get signed off? Why would this require anything other than, if all else fails, eventually disciplining those who don't sign off meds and treatments? Why the heck would that ever be a co-worker's problem to police? And how does the problem of "failure to chart" go away with eMARS?

[kcochrane]

Lol. That relieved some stress for today. Thanks JKL33.

[kcochrane]

For those who "grew up" in the days of paper MARs, holes were a big thing. Especially in LTC, where a given patient's MARs can be VERY numerous, with some things needing to be signed off QID, for example.

Admin would say that these are med errors, because "if it's not charted, it's not done." (My experience has taught me that "just because it's charted, doesn't mean it was done", but that's another story altogether...)

We would have nights audit the MARs and make notes of the holes. Sometimes the DON would do it as well. It was an eternal battle with no end in sight...

Yes it is an eternal battle with no end in sight. Every LTC facility I worked with seemd to have this issue. I was in the habit of double checking my MARs at the end of the night. But I realize sometimes it is just too busy to have time. The solution here is to make the next shift check for "holes". That is a problem when the next shift comes in late, the previous shift is still passing meds or any other staffing issue. Just not a good solution. As a nurse manager I could check the MARs myself and probably will have too.

[kcochrane]

I was around for paper MARs. :)

Never worked as an RN in LTC though. So the holes being referred to are those tiny check-boxes - empty because something didn't get signed off? Why would this require anything other than, if all else fails, eventually disciplining those who don't sign off meds and treatments? Why the heck would that ever be a co-worker's problem to police? And how does the problem of "failure to chart" go away with eMARS?

These are in most cases LPNs. The admins before me thought that policing each other would work. It isn't. So as a nurse manager it's falling on me to decide on how to proceed. Checking the MARs every night before I leave is just one other audit I don't need, but will probably have to do. "Holes" or failure to chart won't go away with eMARs, but the nurse will be made aware of the omissions at the end of the shift that need to be fixed. I'm sure reports can be run in minutes that I can use to discipline as opposed to hours combing through paper charts.

[JKL33]

That makes sense.

I'm sure there is no easy answer to this problem, I just feel that for the most part it's inappropriate to ask nurses not in supervisory positions to police each other's day-to-day work. Although it's a very common (attempted) solution, it creates more problems than it solves, including time directly subtracted from patient care - which is always problem #1 on my list when it comes to these things. Beyond that, it's just an unpleasant/uncomfortable position for adults on either end.

Positively conveying the importance of all care being charted, allowing for a small margin of error, and then disciplining outliers seems to be the main reasonable course of action that over time might lead to fewer charting misses. Or some sort of incentive could be offered, but I realize that can be problematic, too.

[Neats, BSN]

What I do is have a policy that the MAR charting must be complete on each shift. When a nurse has "holes" I ask the nurse to fix them initially, after this they get a copy of the policy, after that they get written up and after 6 unexcused "holes" they are terminated. Is this harsh...yes but there are F-Tags I do not want to get because the nurse has got caught up in something else.

[TriciaJ, RN]

Do the MARs just contain meds, or also treatments, wound care and skin checks? Some facilities put everything on the MAR. If a med wasn't available, or a treatment couldn't be completed for any reason, that leaves a hole in the MAR. When the State audits, the facility gets dinged on the holes.

I think this is mainly a function of poor staffing levels. Facilities emphasize initialing all the little squares; they don't always care whether the thing got done. After all, if something was charted but not really done, then they can just throw the nurse under the bus for fraudulent charting. But they don't always provide the resources to actually get everything done; just make sure all the holes are filled...